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Employment Application
Your Information
EHS does not discriminate on the basis of race, religion, color, national origin, age, veteran, family status, sex, or sexual identity.
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1.
Which office are you applying for?
(Required.)
Lynchburg
Martinsville
Roanoke
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2.
Position applying for:
(Required.)
MHSS Clinician
Clinical Coordinator
Office Manager
SA Counselor
SA Case Manager
Peer Support Specialist
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3.
How did you hear of this position?
(Required.)
Indeed
EHS Website
Facebook
Current Employee
Craigslist
Other (please specify)
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4.
Contact Information
(Required.)
Full Name
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Address
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Address 2
City/Town
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State/Province
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AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
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Email Address
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Phone Number
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5.
Date you're available to start work:
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
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6.
Available:
(Required.)
Full-time
Part-time
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7.
Do you have relatives working for EHS?
(Required.)
Yes
No
If yes, please list:
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8.
Have you ever been employed by EHS?
(Required.)
Yes
No
If yes, when?
9.
If you have worked for EHS under another name, please list name(s):
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10.
Do you have the legal right to work in the U.S.?
Note: If hired, proof of identity and authorization to work in the U.S. will be required.
(Required.)
Yes
No
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11.
Will you now or in the future require sponsorship for employment visa status?
(Required.)
Yes
No
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12.
If applying for a position that requires driving a personal vehicle, do you have a valid license and proof of insurance?
(Required.)
Yes
No
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13.
EHS Driver Safety Policy requires a motor vehicle record check for all employees who drive vehicles for related position duties. Do you have any driving offenses on your record?
(Required.)
Yes
No
If yes, give details. (offense, place of occurrence, date, penalty) below.
Note:
Convictions are not an automatic bar to employment. Each case is considered on its individual merits and the position for which you have applied. However, false statements or material omissions will result in not being hired or terminated from employment.
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